Triennial Compliance Assessment
Of
PrimeWest Health System
Performed under Interagency Agreement for:
Minnesota
Department of Human Services
By
Minnesota Department of Health (MDH)
Managed Care Systems Section
Exam Period:
June 1, 2011 – August 31, 2014
File Review Period:
September 1, 2013 – August 31, 2014
On-site:
October 20 – 23, 2014
Examiners:
Susan Margot, MA
Elaine Johnson, RN, BS, CPHQ
Kate Eckroth, MPH
Final Summary Report
December 23, 2014
Executive Summary
Triennial Compliance Assessment (TCA)
PrimeWest Health System
Federal statutes require DHS to conduct on-site assessments of each contracted MCO to ensure they meet minimum
contractual standards. Beginning in calendar year 2007, during MDH’s managed care licensing examination (MDH QA
Examination) MDH began collecting (on-behalf of DHS) on-site supplemental compliance information. This information
is needed by to meet federal BBA external quality review regulations and is used by the External Quality Review
Organization (EQRO) along with information from other sources to generate a detailed annual technical report (ATR).
The ATR is an evaluation of MCO compliance with federal and state quality, timeliness and access to care requirements.
The integration of the MDH QA Examination findings along with supplemental information collected by MDH (triennial
compliance assessment- TCA) meets the DHS federal requirement.
TCA Process Overview
DHS and MDH collaborated to redesign the SFY 2013 TCA processes, simplifying timelines and corrective action plan
submissions, and adding a step to confirm MCO compliance with corrective action plans. The basic operational steps
remain the same however; when a TCA corrective action plan is needed, the MCO will submit the TCA Corrective Action
Plan to MDH following the MDH corrective action plan submission timelines. When the final QA Examination Report is
published, the report will now include the final TCA Report. Although the attachment of the final TCA Report to the QA
Examination Report is a minor enhancement, this will facilitate greater public transparency and simplify finding
information on state managed care compliance activities. Below is an overview of the SFY 2013 TCA process steps:
•
The first step in the process is the collection and validation of the compliance information by MDH. MDH’s desk
review and on-site QA Examination includes the collection and validation of information on supplemental federal and
public program compliance requirements. To facilitate this process the MCO is asked to provide documents as
requested by MDH.
•
DHS evaluates information collected by MDH to determine if the MCO has “met” or “not met” Contract
requirements. The MCO will be furnished a Preliminary TCA Report to review DHS’ initial “met/not met”
determinations. At this point, the MCO has an opportunity to refute erroneous information but may not submit new or
additional documentation. Ample time and opportunities are allowed during the QA Examination to submit
documents, policies and procedures, or other information to demonstrate compliance. The MCO must refute
erroneous TCA finding within 30 days. TCA challenges will be sent by the MCO to MDH. MDH will forward the
MCO’s TCA rebuttal comments to DHS for consideration.
•
Before making a final determination on “not-met” compliance issues, DHS will consider TCA rebuttal comments by
the MCO. DHS will then prepare a final TCA Report that will be sent to MDH and attached to the final QA
Examination Report. As a result of attaching the final TCA Report to the QA Examination Report, greater public
transparency will be achieved by not separating compliance information and requiring interested stakeholder to query
two state agencies for managed care compliance information.
•
The MCO will submit to MDH a corrective action plan (CAP) to correct not-met determinations. The MCO TCA
CAP must be submitted to MDH within 30 days. If the MCO fails to submit a CAP, and/or address contractual
obligation compliance failures, then financial penalties will be assessed.
•
Follow-up on the MCO TCA CAP activities to address not-met issues by MDH. During the on-site MDH Mid-cycle
QA Exam, MDH will follow-up on TCA not-met issues to ensure the MCO has corrected all issues addressed in the
TCA Corrective Action Plan. CAP follow-up findings will be submitted to DHS for review and appropriate action
will be initiated by DHS if needed.
DHS Triennial Compliance Assessment (TCA)
TCA Data Collection Grid
SFY
Managed Care Organization (MCO)/County Based Purchaser (CBP): PrimeWest Health System
Examination Period: June 1, 2011 – August 31, 2014
Onsite Dates: October 20 – 24, 2014
Table of Contents
1.
QI Program Structure- 2012 Contract Section 7.1.1. .................................................................................................................................. 2
2.
Accessibility of Providers -2012 MSHO/MSC+ Contract Section 6.1.4(C)(2) and 6.1.5(E) ..................................................................... 3
3.
Utilization Management - 2012 Contract Section 7.1.3 ............................................................................................................................. 4
4.
Special Health Care Needs 2012 Contract Section 7.1.4 (A-C................................................................................................................... 7
5.
Practice Guidelines -2012 Contract Section 7.1.5 ...................................................................................................................................... 8
6.
Annual Quality Assessment and Performance Improvement & Program Evaluation-............................................................................... 9
7.
Performance Improvement Projects -2012 Contract Section 7.2.............................................................................................................. 10
8.
Disease Management -2012 Contract Section 7. 3 ................................................................................................................................... 11
9.
Advance Directives Compliance - 2012 Contract Section 16 .................................................................................................................. 13
10.
Validation of MCO Care Plan Audits for MSHO and MSC+ .................................................................................................................. 15
11.
Information System ................................................................................................................................................................................... 16
12 A. Subcontractors........................................................................................................................................................................................... 17
Attachment A: ....................................................................................................................................................................................................... 20
1
DHS Triennial Compliance Assessment (TCA)
TCA Data Collection Grid
SFY 2014
Managed Care Organization (MCO)/County Based Purchaser (CBP): PrimeWest Health System
Examination Period: June 1, 2011 – August 31, 2014
Onsite Dates: October 20 – 24, 2014
DHS Contractual Element and References
1. QI Program Structure- 2012 Contract Section 7.1.1. The
Met/
Not Met
Met
Audit Comments
Approved by MDH June 30, 2014
MCO must incorporate into its quality assessment and improvement program
the standards as described in 42 CFR 438, Subpart D (access, structure and
operations, and measurement and improvement).
Access Standards
42 CFR § 438.206 Availability of Services
42 CFR § 438.207 Assurances of Adequate Capacity and Services
42 CFR § 438.208 Coordination and Continuity of Care
42 CFR § 438.210 Coverage and Authorization of Services
Structure and Operations Standards
42 CFR § 438.214 Provider Selection
42 CFR § 438.218 Enrollee Information
42 CFR § 438.224 Confidentiality and Accuracy of Enrollee Records
42 CFR § 438.226 Enrollment and Disenrollment
42 CFR § 438.228 Grievance Systems
42 CFR § 438.230 Subcontractual Relationships and Delegation
Measurement Improvement Standards
42 CFR § 438.236 Practice Guidelines
42 CFR § 438.240 Quality Assessment and Performance Improvement
Program
2
DHS Contractual Element and References
2.
Accessibility of Providers -2012 MSHO/MSC+ Contract Section
6.1.4(C)(2) and 6.1.5(E)
A. In accordance with the DHS/MCO managed care contracts for MSHO
and MSC+, the MCO must demonstrate that it offers a range of
choice among Waiver providers such that there is evidence of
procedures for ensuring access to an adequate range of waiver and
nursing facility services and for providing appropriate choices among
nursing facilities and/or waiver services to meet the individual need as
of Enrollees who are found to require a Nursing Facility Level of Care.
These procedures must also include strategies for identifying
Institutionalized Enrollees whose needs could be met as well or better
in non-Institutional settings and methods for meeting those needs, and
assisting the Institutionalized Enrollee in leaving the Nursing Facility
Met/
Not Met
Met
Audit Comments
PWH provided excerpts from 3 documents that, read together, briefly
describe its strategies for identifying institutionalized enrollees whose
needs could be met in the community.
PWH could better meet this element by including all the excerpts in one
policy/procedure.
3
DHS Contractual Element and References
3.
Utilization Management - 2012 Contract Section 7.1.3
Met/
Not Met
Met
Audit Comments
A. The MCO shall adopt a utilization management structure consistent
with state regulations and current NCQA “Standards for Accreditation
of Health Plans.” 1 The MCO shall facilitate the delivery of appropriate
care and monitor the impact of its utilization management program to
detect and correct potential under and over utilization. The MCO shall:
i. Choose the appropriate number of relevant types of utilization data,
including one type related to behavioral health to monitor.
ii. Set thresholds for the selected types of utilization data and annually
quantitatively analyze the data against the established thresholds to
detect under and overutilization.
iii. Conduct qualitative analysis to determine the cause and effect of all
data not within thresholds.
iv. Analyze data not within threshold by medical group or practice.
v. Take action to address identified problems of under or
overutilization and measure the effectiveness of its interventions. 2
B. The following are the 2012 NCQA Standards and Guidelines for the
Accreditation of MCOs UM 1-4 and 10-14.
NCQA Standard UM 1: Utilization Management Structure. The
organization clearly defines the structures and processes within its utilization
management (UM) program and assigns responsibility to appropriate
individuals.
Element A: Written Program Description
Element B: Physician Involvement
Element C: Behavioral Health Involvement
Element D: Annual Evaluation
Met
Met through NCQA. Accreditation audit
NCQA conducted a survey of PWH Medicaid products. During the survey,
NCQA reviewed policies/procedures, but did not review files or HEDIS
data. Therefore, PrimeWest received an “Interim Accreditation” effective
July 1, 2014 through January 14, 2016. PrimeWest earned 100% of all
possible points in the NCQA survey of policies/procedures. Therefore,
consistent with MDH/DHS practice with NCQA accredited MCOs, these
contract provisions are “Met through NCQA.”
1 2011 Standards and Guidelines for the Accreditation of Health Plans, effective July 1, 2011
2 42 CFR 438. 240(b)(3)
4
Met/
Not Met
Met
Met through NCQA Accreditation audit
NCQA Standard UM 3: Communication Services
The organization provides access to staff for members and practitioners seeking
information about the UM process and the authorization of care.
(a)
Element A: Access to Staff
Met
Met through NCQA Accreditation audit
NCQA Standard UM 4: Appropriate Professionals
Qualified licensed health professionals assess the clinical information used to
support UM decisions.
(a)
Element D: Practitioner Review of BH Denials
(b)
Element F: Affirmative Statement About Incentives
Met
Met through NCQA Accreditation audit
NCQA Standard UM 10: Evaluation of New Technology
The organization evaluates the inclusion of new technologies and the new
application of existing technologies in the benefits plan. This includes medical
and behavioral health procedures, pharmaceuticals, and devices.
(a)
Element A: Written Process
(b)
Element B: Description of the Evaluation Process
(c)
Element C: Implementation of New Technology
Met
Met through NCQA Accreditation audit
NCQA Standard UM 11: Satisfaction with the UM Process
The organization evaluates member and practitioner satisfaction with the UM
process.
(a)
Element A: Assessing Satisfaction with UM Process.
Met
Met through NCQA Accreditation audit
DHS Contractual Element and References
NCQA Standard UM 2: Clinical Criteria for UM Decision
To make utilization decisions, the organization uses written criteria based on
sound clinical evidence and specifies procedures for appropriately applying the
criteria.
(a)
Element A: UM Criteria
(b)
Element B: Availability of Criteria
(c)
Element C: Consistency in Applying Criteria
Audit Comments
5
DHS Contractual Element and References
Met/
Not Met
Met
Audit Comments
Met through NCQA Accreditation audit
Met
Met through NCQA Accreditation audit
Met
Met through NCQA Accreditation audit
NCQA Standard UM 12: Emergency Services. The organization provides,
arranges for or otherwise facilitates all needed emergency services, including
appropriate coverage of costs.
Element A: Policies and Procedures
NCQA Standard UM 13: Procedures for Pharmaceutical Management.
The organization ensures that its procedures for pharmaceutical management, if
any, promote the clinically appropriate use of pharmaceuticals
Element A: Policies and Procedures
Element B: Pharmaceutical Restrictions/Preferences
Element C: Pharmaceutical Patient Safety Issues
Element D: Reviewing and Updating Procedures
Element F: Availability of Procedures
Element G: Considering Exceptions
NCQA Standard UM 14: Triage and Referral to Behavioral Health. The
organization has written standards to ensure that any centralized triage and
referral functions for behavioral health services are appropriately implemented,
monitored and professionally managed. This standard applies only to
organizations with a centralized triage and referral process for
behavioral health, both delegated and non-delegated
Element A: Triage and Referral Protocols
6
DHS Contractual Element and References
4. Special Health Care Needs 2012 Contract Section 7.1.4 (AC)3, 4 The MCO must have effective mechanisms to assess the quality and
Met/
Not Met
Met
Audit Comments
appropriateness of care furnished to Enrollees with special health care needs.
A. Mechanisms to identify persons with special health care needs,
B. Assessment of enrollees identified, (Senior and SNBC Contract – care
plan) and
C. Access to specialists
3 42 CFR 438.208 (c)(1-4)
4 MSHO, MSC+ Contract section 7.1.4 A, C;
7
DHS Contractual Element and References
5. Practice Guidelines -2012 Contract Section 7.1.5 5,6,
A. The MCO shall adopt preventive and chronic disease practice guidelines
appropriate for children, adolescents, prenatal care, young adults, adults,
and seniors age 65 and older, and, as appropriate, for people with
disabilities populations.
i. Adoption of practice guidelines. The MCO shall adopt guidelines
based on:
• Valid and reliable clinical evidence or a consensus of Health Care
Professionals in the particular field
• Consideration of the needs of the MCO enrollees
• Guidelines being adopted in consultation with contracting Health Care
Professionals
• Guidelines being reviewed and updated periodically as appropriate.
ii. Dissemination of guidelines. MCO ensures guidelines are
disseminated: to all affected Providers; and to enrollees and potential
enrollees upon request
iii. Application of guidelines. MCO ensures guidelines are applied to
decisions for:
• Utilization management
• Enrollee education
• Coverage of services
• Other areas to which there is application and consistency with the
guidelines.
Met/
Not Met
Met
Audit Comments
PWH monitors clinics that consistently follow (or do not follow) PWH
practice guidelines. As a result of the monitoring, PWH implemented a
quality-driven alternative reimbursement strategy with some providers.
(Explained in their ARCH report.) Providers report data through MN
Community Measurement at the medical group/clinic level.
5 42 CFR 438.236
6 MSHO/MSC+ Contract section 7.2 A-C
8
DHS Contractual Element and References
6. Annual Quality Assessment and Performance Improvement
Program Evaluation- 2012Contract Sections 7.1.8 7,8
Met/
Not Met
Met
Audit Comments
A. The MCO must conduct an annual quality assessment and performance
improvement program evaluation consistent with state and federal
regulations and current NCQA “Standards for Accreditation of Health
Plans”. This evaluation must:
i.
Review the impact and effectiveness of the MCO’s quality
assessment and performance improvement program
ii. Include performance on standardized measures (example: HEDIS®)
and
iii. Include MCO’s performance improvement projects.
B. NCQA QI 1, Element B: There is an annual written evaluation of the
QI Program that includes:
i.
A description of completed and ongoing QI activities that address
quality and safety of clinical care and quality of service
ii. A trending of measures to assess performance in the quality and
safety of clinical care and quality of services
iii. Analysis of the results of QI initiatives, including barrier analysis
iv. Evaluation of the overall effectiveness of the QI program, including
progress toward influencing network-wide-safe clinical practices
7 42 CFR 438.240(e)
8 MSHO/MSC+ Contract Section 7.2.4 also includes the requirement that the MCO must include the “Quality Framework for the Elderly” in its Annual Evaluation
9
DHS Contractual Element and References
7. Performance Improvement Projects -2012 Contract Section
7.2 9.10,11
A. Interim Project Reports. By December 1st of each calendar year, the
MCO must produce an interim performance improvement project
report for each current project. The interim project report must include
any changes to the project(s) protocol steps one through seven and
steps eight and ten as appropriate.
Met/
Not Met
Met
Audit Comments
Interim:
Colorectal CA Screening – 2012, 2013 – Dated December 1
Post-DISCHARGE Member Follow-up – 2012, 2013 – December 1
LDL SCREENING AMONG Members with Diabetes – November 27
HPV Vaccination for Males – 2013- December 1
Completed:
HPV Female Adolescents
ASA Therapy
Diabetes BP
B. Completed (Final) Project Reports: Completed PIP Project
Improvements Sustained over Time- Real changes in fundamental
system processes result in sustained improvements:
i
Were PIP intervention strategies sustained following project
completion?
ii. Has the MCO monitored post PIP improvements?
9 42 CFR 438.240 (d)(2)
10 MSHO/MSC+ Contract section 7.3
11 CMS Protocols, Conduction Performance Improvement Projects, Activity 10
10
DHS Contractual Element and References
8. Disease Management -2012 Contract Section 7. 3 12 The MCO
Met/
Not Met
Met
Audit Comments
NCQA 100% compliance
shall make available a Disease Management Program for its Enrollees with:
A. Diabetes
B. Asthma
C. Heart Disease
Standards -The MCO‘s Disease Management Program shall be consistent
current NCQA “Standards and Guidelines for the Accreditation of Health
Plans” – QI Standard Disease Management
If the MCO’s Diabetes, Asthma, and Heart Disease Management Programs
have achieved 100% compliance during the most recent NCQA Accreditation
Audit of QI Standards- Disease Management, the MCO will not need to further
demonstrate compliance.
Diabetes:
B. Program Content
C. Identifying Members for DM Programs
D. Frequency of Member Identification
E. Providing Members With Information
F. Interventions Based on Stratification
G. Eligible Member Participation
H. Informing and Educating Practitioners
I. Integrating Member Information
J. Satisfaction With Disease Management
K. Measuring Effectiveness
Asthma:
B. Program Content
C. Identifying Members for DM Programs
D. Frequency of Member Identification
12 MSHO/ MSC+ Contract section 7.4, requires only diabetes and hearth DM programs; SNBC Contract section 7.2.9
11
DHS Contractual Element and References
Met/
Not Met
Audit Comments
E. Providing Members With Information
F. Interventions Based on Stratification
G. Eligible Member Participation
H. Informing and Educating Practitioners
I. Integrating Member Information
J. Satisfaction With Disease Management
K. Measuring Effectiveness
Heart Disease:
B. Program Content
C. Identifying Members for DM Programs
D. Frequency of Member Identification
E. Providing Members With Information
F. Interventions Based on Stratification
G. Eligible Member Participation
H. Informing and Educating Practitioners
I. Integrating Member Information
J. Satisfaction With Disease Management
K. Measuring Effectiveness
12
DHS Contractual Element and References
9. Advance Directives Compliance - 2012 Contract Section
16 13,14
Met/
Not Met
Met
A. The MCO agrees to provide all Enrollees at the time of enrollment
a written description of applicable State law on advance directives
and the following:
i. Information regarding the enrollee’s right to accept or refuse
medical or surgical treatment; and to execute a living will,
durable power of attorney for health care decisions, or other
advance directive.
ii. Written policies of the MCO respecting the implementation of
the right; and
iii. Updated or revised changes in State law as soon as possible,
but no later than 90 days after the effective date of the change;
iv. Information that complaints concerning
noncompliance with the Advance Directive
requirement may be filed with the State survey and
certification agency (i.e. Minnesota Department of
Health), pursuant to 42 CFR 422.128 as required in
42 CFR 438.6(i).
Audit Comments
PWH’s goal is that all enrollees will have an advance directive and meets
this requirement by including the measure on the medical record review
audit tool. Annually provider compliance is measured and reported in the
medical record review report.
B. Providers. To require MCO’s providers to ensure that it has been
documented in the enrollee’s medical records whether or not an
individual has executed an advance directive.
C. Treatment. To not condition treatment or otherwise discriminate
on the basis of whether an individual has executed an advance
directive.
D. To comply with State law, whether statutory or recognized by the
13 42 C.F.R. 489.100. Pursuant to 42 U.S.C. 1396a(a)(57) and (58) and 42 C.F.R. 489.100-104
14 MSC/MSC+ Contract Article 16;
13
DHS Contractual Element and References
Met/
Not Met
Audit Comments
courts of the State on Advance Directives, including Laws of
Minnesota 1998, Chapter 399, §38.
E. To provide, individually or with others, education for MCO staff,
providers and the community on Advance Directives.
14
DHS Contractual Element and References
10.
Validation of MCO Care Plan Audits for MSHO
and MSC+ 15,.
MDH will collect information for DHS to monitor MCO Care
Plan Audit activities as outlined in the DHS/MCO
MSHO/MSC+ Contract.
A. DHS will provide MDH with Data Collection Guide
for the random sample of 30 MCO enrollees (plus an
over sample of 10 MCO enrollees for missing or
unavailable enrollee records) for MSHO and MSC+
program. Of the 40 records sampled, 20 records will
be for members new to the MCO within the past 12
months and other 20 records will be for members
who have been with the MCO for more than 12
months.
B.
C.
D.
MDH will request the MCO make available during
the MDH QA Examination on-site audit the
identified enrollee records. A copy of the data
collection instruction sheet, tool and guide will be
included with MDH's record request.
An eight-thirty audit methodology will be used to
complete a data collection tool for each file in each
sample consistent with the Data Collection Guide.
Within 60 days of completing the on-site MDH QA
Examination, MDH will provide DHS with a brief
report summarizing the data collection results, any
other appropriate information and the completed data
collection tools.
Met/
Not Met
Met
Audit Comments
MDH found no errors in the EW Care Plan file sample. In one initial
assessment, the plan’s last assessment was in July 2013; an initial
assessment occurred in October (new to PWH); the reassessment occurred
in June 2014. In addition, the signatures on the initial assessment (new to
PWH) were from June 2013.
DHS informs us that an assessment has to be done within a year “of the last
assessment. “ Reassessment can be done early as there could be a good
reason such as change of condition. If that is the case, a reassessment is not
due until one year from that last assessment. Health plans may try to keep
the initial assessment date intact and if that is the case, may reassess when
that one year comes up.
The plan needs to be careful doing assessment early especially when PCA
is involved because a person’s assessment is to last a full year and if an
early assessment would result in reduction of hours, they would need to
continue the higher level of services through the whole year of the
assessment. To state there is not a prohibition to conducting reassessments
early is not completely accurate. There has to be a request for a
reassessment or change in condition.
If a new care plan or CSP is created based on an assessment, a new
signature is required. If there were no changes to the CSP or care plan,
then the existing signed care plan is the care plan of record.
The file did not include PCA services. Since MDH is unsure if the CSP
lead to any change in services, we did not have any finding regarding the
file. However, MDH includes the caution raised by DHS in the TCA.
DHS Comment: DHS (Aging waiver staff) has not defined “annually” so
there is not a definition in the contract. However, Aging staff are now
indicting reassessments need to be done every 366 days. This more closely
aligns with Medicare’s 365 definitions. It is expected this changes will be
incorporated into an updated care plan audit document.
15 Pursuant to MSHO/MSC+ 2011 Contract sections 6.1.4(A)(2), 6.1.4(A)(3), 6.1.4(A)(4), 6.1.5(B)(4), 6.1.5(B)(5)
15
DHS Contractual Element and References
11. Information System.
16, 17
The MCO must operate an
information system that supports initial and ongoing
operations and quality assessment and performance
improvement programs.
The MCO must maintain a health information system that
collects, analyzes, integrates, and reports data. During each of
the past three years, all MCO MDH annual HEDIS
performance measures have been certified reportable by an
NCQA HEDIS audit.
Met/
Not Met
Met
Audit Comments
HEDIS Audit Reports submitted for review for years:
1. 2011 MetaStar
2. 2012 Metastar
3. 2013 MetaStar
PrimeWest Health submitted measures were prepared according to HEDIS
Technical Specifications.
16 Families and Children, and Seniors
17 42 CFR 438.242
16
DHS Contractual Element and References
12 A. Subcontractors. 18 Written Agreement;
Disclosures. All subcontracts must be in writing and must include a
specific description of payment arrangements. All subcontracts are
subject to STATE and CMS review and approval, upon request by the
STATE and/or CMS. Payment arrangements must be available for
review by the STATE and CMS. All contracts must include:
A. Disclosure of Ownership and Management Information
(Subcontractors). In order to assure compliance with 42 CFR
§ 455.104, the MCO, before entering into or renewing a
contract with a subcontractor, must request the following
information:
(1) The name, address, date of birth, social security
number (in the case of an individual), and tax
identification number (in the case of a corporation)
of each Person, with an Ownership or Control
Interest in the disclosing entity or in any
subcontractor in which the disclosing entity has
direct or indirect ownership of five percent (5%) or
more. The address for corporate entities must
include primary business address, every business
location and P.O. Box address;
(2) A statement as to whether any Person with an
Ownership or Control Interest in the disclosing entity
as identified in 9.3.1(A) is related (if an individual)
to any other Person with an Ownership or Control
Interest as spouse, parent, child, or sibling;
(3) The name of any other disclosing entity in which a
Person with an Ownership or Control Interest in the
disclosing entity also has an ownership or control
interest; and
(4) The name, address, date of birth, and social security
number of any managing employee of the disclosing
entity.
Met/
Not Met
Met
Audit Comments
All contracts/delegation agreements reviewed included specific payment
arrangements.
PWH’s “contract package” includes a form with disclosure information as
required.
18Families and Children Contract Sections 9.1.3.A, 9.1.3.C
17
DHS Contractual Element and References
Met/
Not Met
Audit Comments
(5) For the purposes of section 9.3, subcontractor means
an individual, agency, or organization to which a
disclosing entity has contracted, or is a person with
an employment, consulting or other arrangement
with the MCO for the provision of items and services
that are significant and material to the MCO’s
obligations under its Contract with the STATE.
C. Upon request, subcontractors must report to the MCO
information related to business transactions in accordance
with 42 CFR §455.105(b). Subcontractors must be able to
submit this information to the MCO within fifteen (15)
days of the date of a written request from the STATE or
CMS. The MCO must report the information to the
STATE within ten (10) days of the MCO’s receipt from
the subcontractor.
Exclusions of Individuals and Entities; Confirming Identity.19
(A) Pursuant to 42 CFR § 455.436, the MCO must confirm the identity
and determine the exclusion status of Providers and any Person
with an Ownership or Control Interest or who is an agent or
managing employee of the MCO or its subcontractors through
routine checks of Federal databases, including the Social Security
Administration's Death Master File and the National Plan and
Provider Enumeration System (NPPES), and also upon contract
execution or renewal, and credentialing.
Policy/procedure and contract so requires
Met
PWH conducts background checks on each of its board members and
leadership. All providers are credentialed including NPDB, EPLS and the
OIG checks.
PWH delegates its subcontractors the function of conducting searches.
(B) The MCO and its subcontractors must search monthly, and upon
contract execution or renewal, and credentialing, the OIG List of
Excluded Individuals/Entities (LEIE) and the Excluded Parties
List System (EPLS, within the HHS System for Awards
Management) database (and may search the Medicare Exclusion
Database), for any Providers, agents, Persons with an Ownership
or Control Interest, and Managing Employees to verify that these
persons:
1.
2.
Are not excluded from participation in Medicaid under
Sections 1128 or 1128A of the Social Security Act; and
Have not been convicted of a criminal offense related to that
19 Families and Children Contract Section 9.3.13
18
DHS Contractual Element and References
Met/
Not Met
Audit Comments
person’s involvement in any program established under
Medicare, Medicaid or the programs under Title XX of the
Social Security Act.
(C) The MCO must require subcontractors to assure to the MCO that
no agreements exist with an excluded entity or individual for the
provision of items or services related to the MCO’s obligation
under this Contract.
(D) The MCO shall require all subcontractors to report to the MCO
within five (5) days any information regarding individuals or
entities specified in (A) above, who have been convicted of a
criminal offense related to the involvement in any program
established under Medicare, Medicaid, the programs under Title
XX of the Social Security Act, or that have been excluded from
participation in Medicaid under §§ 1128 or 1128A of the Social
Security Act.
(E) The MCO shall report this information to the STATE within seven
(7) days of the date the MCO receives the information
.
(F) The MCO must also promptly notify the STATE of any action
taken on a subcontract under this section, consistent with 42 CFR
§ 1002.3 (b)(3).
(G)
In addition to complying with the provisions of section 9.9, the
MCO shall not enter into any subcontract that is prohibited, in
whole or in part, under § 4707(a) of the Balanced Budget Act of
1997 or under Minnesota Statutes, § 62J.71.
19
Attachment A:
MDH 2014 EW Care Plan Audit
Audit
Protocol
Protocol Description
Measures
Total # Charts
Reviewed
Initial
1
2
3
INITIAL HEALTH
RISK ASSESSMENT
For members new to the
MCO or product within
the last 12 months
ANNUAL HEALTH
RISK ASSESSMENT
For members on who
have been a member of
the MCO for more than
12 months
[Only for plans with
separate HRA]
LONG TERM CARE
CONSULTATION –
INITIAL
If member is new to
EW in the past 12
months
Reassessment
Total # Charts “Met”
Initial
2014
Total
% Met
Reassessment
A. Date HRA completed
is within 30 calendar days
of enrollment date
B. All HRA areas
evaluated and
documented (in enrollee
Comprehensive Care
Plan)
HRA is completed is
within 12 months of
previous HRA
(results are included in
enrollee Comprehensive
Care Plan)
8
8
100%
8
8
100%
A. All (100%) of the
fields relevant to the
enrollee’s program are
completed with pertinent
information or noted as
Not Applicable or Not
Needed
B. LTCC was completed
timely (and in enrollee
Comprehensive Care
Plan)
8
8
100%
8
8
100%
8
Comments
8
100%
20
4
5
6
REASSESSMENT OF
EW
For members open to
EW who have been a
member of the MCO
for more than 12
months
COMPREHENSIVE
CARE PLAN
Includes needs
identified in the HRA
and/or the LTCC and
other sources such as
medical records and
member and/or family
input and all elements
of the community
support plan.
COMPREHENSIVE
CARE PLAN
SPECIFIC
A. Date re-assessment
completed is within 12
months of previous
assessment
B. All areas of LTCC
have been evaluated and
documented
(and in enrollee
Comprehensive Care
Plan)
A. Date Comprehensive
Care Plan was completed
is within 30 calendar days
of completed LTCC
(“Complete” defined as
the date the plan is ready
for signature (may also be
noted as “date sent to
member”
B. If enrollee refused
recommended HCBS care
or service, then refusal
should be noted in the
Comprehensive Care Plan
according to item IV of
the CSP as evidence of a
discussion between care
planner and enrollee
about how to deal with
situations when support
has been refused,
referred to as the personal
risk management plan
A. Identification of
enrollee needs and
concerns, including
8
8
100%
8
8
100%
8
8
8
8
100%
8
8
8
8
100%
8
8
8
8
100%
21
ELEMENTS
To achieve an
interdisciplinary,
holistic, and preventive
focus; the
Comprehensive Care
Plan must include the
elements listed:
7
FOLLOW-UP PLAN
Follow-up plan for
contact for preventive
care20, long-term care
and community support,
identification of health
and safety risks, and what
to do in the event of an
emergency, are
documented in
Comprehensive Care Plan
and linked to assessed
needs as determined by
the completed LTCC
B. Goals and target dates
(at least, month/year)
identified
Monitoring of outcomes
and achievement dates (at
least, month/year) are
documented
C. Outcomes and
achievement dates (at
least, month/year) are
documented
D. If the enrollee refuses
any of the recommended
interventions, the
Comprehensive Care Plan
includes documentation
of an informed choice
about their care and
support
A. All areas of concern
are addressed as
identified on the
Comprehensive Care Plan
as stated in #5 of this
8
8
8
8
100%
8
8
8
8
100%
8
8
8
8
100%
8
8
8
8
100%
20 Preventive care concerns may include but not be limited to: annual physical, immunizations, screening exams such as dementia screening, vision and hearing
exams, health care (advance) directive, dental care, tobacco use, and alcohol use.
22
medical care, or mental
health care21, or any
other identified concern
8
ANNUAL
PREVENTIVE CARE
9
ADVANCE
DIRECTIVE
protocol
B. If an area is noted as a
concern then there must
be documented goals,
interventions, and
services for concerns or
needs identified
[If an area is identified as
not a concern, then “Not
Needed” and will be
excluded from
denominator for this item]
Documentation in
enrollee’s Comprehensive
Care Plan that
substantiates a
conversation was initiated
with enrollee about the
need for an annual, age–
appropriate
comprehensive preventive
health exam (i.e.,
Influenza immunization,
Pneumococcal
immunization, Shingles
(Zostavax) immunization,
Vision screening,
Depression screening (or
other mental status
review), Assessment of
the presence of urinary
incontinence, Preventive
dental exam
Evidence that a
discussion was initiated,
8
8
8
8
100%
8
8
8
8
100%
8
8
8
8
100%
21 Mental health care concerns should include but not be limited to: depression, dementia, and other mental illness.
23
10
11
12
13
ENROLLEE
CHOICE
Enrollee was given a
choice between Home
and Community-Based
Services (HCBS) and
Nursing Home Services
(also indicates enrollee
involvement in care
planning)
CHOICE OF HCBS
PROVIDERS
Enrollee was given
information to enable
the enrollee to choose
among providers of
HCBS
HOME AND
COMMUNITY
BASED SERVICE
PLAN
A HCBS service plan
with these areas
completed, including
clearly identified and
documented links to
assessed needs per the
results of the LTCC
CAREGIVER
enrollee refused to
complete, was culturally
inappropriate, or AD was
completed
A. Choice noted in
Section J of LTCC
Assessment Form (e-docs
#3428) or equivalent
document (correlates to
Section D of the LTCC
Screening Document (edocs #3427)
B. Completed and signed
care plan summary
(and in enrollee
Comprehensive Care
Plan)
Completed and signed
care plan summary
(and in enrollee
Comprehensive Care
Plan)
8
8
8
8
100%
8
8
8
8
100%
8
8
8
8
100%
A. Type of services to be
furnished
8
8
8
8
100%
B. The amount, frequency
and duration of each
service
C. The type of provider
furnishing each service
including non-paid care
givers and other informal
community supports or
resources
A. Attached Caregiver
8
8
8
8
100%
8
8
8
8
100%
8
8
8
100%
8
See comments in
Summary below
24
SUPPORT PLAN
If a primary caregiver is
identified in the LTCC,
Planning Interview
B. Incorporation of stated
caregiver needs in Service
Agreement, if applicable
8
8
8
8
100%
2013 PWH MSHO/MSC+ Elderly Waiver Care Plan Audit Delegate Summary Report
Audit
Protocol
Number
1
2
3
4
Desired
Outcome
Initial Health
Risk
Assessment
Annual Health
Risk
Assessment
LTCC- Initial
(New to EW in
past 12 months)
Annual
Reassessment of
EW
Description of Protocol
Area
a. Completed within
timelines
b. Results included in CCP
c. All areas evaluated and
documented
a. Completed within
timelines
b. Results included in CCP
a. LTCC results attached to
CCP
b. All relevant fields
completed or “n/a” is doc
c. Completed timely
a. Annual re-assess w/in 12
months of prior assessment
or explanation documented
b. Results of LTCC attached
to CCP
Number
of
Sampled
Care
Plans
Number of
Reviewed
Care Plans
for which
Area is
Applicable
Number
of Care
Plans
with a
“Met”
Score
Percentage
of Care
Plans with a
“Met” Score
Corrective
Action
Indicated
Improvement
Opportunity
88
11
11
11
None
None
88
110
11
13
11
13
11
12
None
One
None
One
88
0
0
0
N/A
N/A
88
0
0
0
N/A
N/A
88
21
21
21
None
None
88
21
21
21
None
None
88
88
21
72
21
72
21
72
None
None
None
None
88
72
72
72
None
None
25
5
Comprehensive
Care Plan
6
Comprehensive
Care Plan
Specific
Elements
7
8
9
10
Personal Risk
Management
Plan
Annual
Preventive
Health Exam
Advance
Directive
Enrollee Choice
c. All areas evaluated and
documented
CCP completed w\in 30 days
of LTCC or explanation
documented
a. Needs & Concerns
identified
b. Goals/target dates
identified
c. Interventions identified
d. Monitoring progress
towards goals
e. Outcome/Achievement
dates are documented
f. Doc of informed choice if
member refuses
recommended interventions
g. Follow up plan for contact
for preventative care, longterm care etc..
a. Service refusal noted in
CCP
b. Personal risk management
plan completed
Annual Preventive health
exam conversation initiated
88
72
72
72
None
None
110
110
110
108
One
One
154
154
154
103
Three
Three
88
88
88
88
None
None
88
110
88
110
88
110
88
103
None
One
None
One
110
110
110
87
One
One
88
26
26
26
None
None
176
176
176
121
Four
Four
88
9
9
9
None
None
88
9
9
9
None
None
88
88
88
88
None
None
Advanced Directive
conversation
a. Sec J or equivalent
document
b. Completed & signed Care
Plan
88
88
88
88
None
None
88
88
88
88
None
None
88
88
88
88
None
None
26
11
12
13
Choice of
HCBS Providers
HCBS Plan
Caregiver
Support Plan
c. Copy of CCP summary
a. Completed & signed Care
Plan
b. Copy of CCP Summary
a. Type of Services
b. Amount, Frequency,
Duration and Cost
c. Type of Provider & nonpaid/informal
d. Attempted not complete
w/explanation
a. Caregiver planning
interview/assessment
attached
b. Incorporated into SA, if
applicable
88
88
88
88
88
88
88
None
None
None
None
88
88
88
88
88
88
88
88
88
88
88
88
None
None
None
None
None
None
88
88
88
88
None
None
88
0
0
0
N/A
N/A
88
24
24
24
None
None
88
24
24
24
None
None
Summary:
DHS followed the sampling methodology outlined in the audit protocol guidelines and presented the sample lists to MDH. MDH
audited eight initial assessment files and eight reassessment files following the MSHO and MSC+ Elderly Waiver Planning Protocol
Care Plan Data Collection Guide.
The PWH 2013 delegate audit (combined) reviewed a larger file sample. All issues identified were in Protocol # 5 and #6:
Completeness of the initial health risk assessment and specific elements of the CCP. PWH indicated if a corrective action was
indicated.
MDH found no errors in the EW Care Plan file sample. We found one issue with one initial assessment. In that file, the plan’s last
assessment was in July 2013; an initial assessment occurred in October (new to PWH); the reassessment occurred in June 2014. The
file did not include PCA services. Since MDH is unsure if the CSP lead to any change in services, we did not have any finding
regarding the file. However, MDH includes the caution raised by DHS in the TCA Element 10 text.
27